For the purpose of this part the following definitions shall apply:

1. (1) “Board” means the State Board of Health;
2. (2) “Certificate” means a certificate of registration granted by the State Board of Health to a private review agent;

3. (3) “Certified private review agent” means a private review agent who has:

   1. (A) Met all the criteria for certification as set forth in this part;
   2. (B) Paid all current fees; and
   3. (C) Been assigned a certification number;
4. (4) “Consulting physician” means a medical doctor, doctor of osteopathy, dentist, or chiropractor who possesses the degree of skill ordinarily possessed and used by members of his or her profession in good standing engaged in the same type of practice and specialty in the locality where the service under review occurred or in a similar locality;
5. (5) “Hospital” means any facility established for the purpose of providing inpatient diagnostic care and treatment for two (2) or more unrelated persons for more than twenty-four (24) hours may not be conducted or maintained in this state without being licensed;

6. (6) “Private review agent” means a nonhospital affiliated entity performing utilization review that is either affiliated with, under contract with, or acting on behalf of an Arkansas business entity or third party that provides or administers hospital and medical benefits to citizens of this state, including a health maintenance organization or entity offering health insurance policies, contracts, or benefits in this state, including a:

   1. (A) Health insurer;
   2. (B) Nonprofit health service plan;
   3. (C) Health insurance service organization; or
   4. (D) Preferred provider organization;
7. (7) “Secretary” means the Secretary of the Department of Health or his or her designee;

8. (8)

   1. (A) “Utilization review” means a system for reviewing the appropriate and efficient allocation of hospital resources and medical services given or proposed to be given to a patient or group of patients.
   2. (B) More specifically, utilization review refers to a preservice determination of the medical necessity or appropriateness of services to be rendered in a hospital setting either on an inpatient or outpatient basis, when such determination results in approval or denial of payment for the services.
   3. (C) It includes prospective, concurrent, or retrospective reviews;
9. (9) “Utilization review plan” means a description of the standards governing utilization review activities performed by a private review agent; and
10. (10) “Utilization review representative” means the person or persons in a physician’s office or hospital designated by the physician or hospital to provide the necessary information to complete the review process.